Family Planning in Asia and the Pacific - International Council on ...

Nam. Nearly all economies <strong>in</strong> <strong>the</strong> <strong>Pacific</strong> region reflectmajor <strong>in</strong>creases <strong>in</strong> donor expenditures on population,except for Fiji, Kiribati <strong>and</strong> Tuvalu.Assum<strong>in</strong>g a relatively constant level of fund<strong>in</strong>g <strong>in</strong>to 2009,<strong>the</strong> per capita expenditure by donors (for women ofchildbear<strong>in</strong>g age <strong>in</strong> union) is $1.49. It varies by subregion,from $0.31 <strong>in</strong> East <strong>Asia</strong> to $4.36 <strong>in</strong> Sou<strong>the</strong>astern <strong>Asia</strong>,to $45.34 <strong>in</strong> <strong>the</strong> <strong>Pacific</strong>, where economies of scale are lessimmediate <strong>and</strong> HIV fund<strong>in</strong>g may be a major contributor.Aga<strong>in</strong>, countries of strategic global <strong>in</strong>terest <strong>and</strong> withspecial sexual <strong>and</strong> reproductive health needs, such asAfghanistan or those <strong>in</strong> Central <strong>Asia</strong>, show higher percapita <strong>in</strong>vestments by donors than o<strong>the</strong>r countries.Although much of <strong>the</strong> fund<strong>in</strong>g data may be driven byrises <strong>in</strong> STI/HIV programme support, <strong>the</strong> latter presentopportunities for family plann<strong>in</strong>g services to be l<strong>in</strong>ked toor <strong>in</strong>tegrated with sexual health <strong>and</strong> exp<strong>and</strong> <strong>the</strong> realmof efforts for prevent<strong>in</strong>g both unplanned pregnancy <strong>and</strong>sexually transmitted <strong>in</strong>fection.The unf<strong>in</strong>ished agenda <strong>and</strong> go<strong>in</strong>gforwardWhile family plann<strong>in</strong>g has been hailed as one of <strong>the</strong> 10greatest public health achievements of <strong>the</strong> twentiethcentury (CDC, 1999), as is <strong>the</strong> case with o<strong>the</strong>r successfulpublic health <strong>in</strong>itiatives, one cannot simply declare victory<strong>and</strong> shift attention <strong>and</strong> resources to ano<strong>the</strong>r health priority.Assur<strong>in</strong>g contraceptive security <strong>in</strong>formation <strong>and</strong> carenecessitates cont<strong>in</strong>ually align<strong>in</strong>g both supply <strong>and</strong> dem<strong>and</strong>factors, us<strong>in</strong>g available public <strong>and</strong> private resources tomeet <strong>the</strong> needs of <strong>the</strong> economically disadvantaged usersforemost, <strong>and</strong> to obta<strong>in</strong> maximum equity <strong>in</strong> care. Nationalconditions for supply <strong>and</strong> dem<strong>and</strong> factors vary considerablyacross <strong>the</strong> <strong>Asia</strong>n <strong>and</strong> <strong>Pacific</strong> region, from highly organizedsystems of service delivery <strong>in</strong> Ch<strong>in</strong>a <strong>and</strong> India, wherenormative dem<strong>and</strong> has <strong>in</strong>creas<strong>in</strong>gly conformed to whatearlier generations of childbear<strong>in</strong>g women have beenprovided, to nascent or underperform<strong>in</strong>g systems, suchas <strong>in</strong> Timor-Leste, Laos or Pakistan, where unsatisfieddem<strong>and</strong> is often high.There are several “certa<strong>in</strong>ties” that will frame <strong>the</strong> futureagenda of family plann<strong>in</strong>g for <strong>the</strong> region: (a) populationmomentum <strong>and</strong> growth <strong>in</strong> <strong>the</strong> population of sexuallyactive <strong>in</strong>dividuals <strong>and</strong> those of childbear<strong>in</strong>g age will placepressure on exist<strong>in</strong>g family plann<strong>in</strong>g resources <strong>in</strong>dependentof o<strong>the</strong>r changes <strong>in</strong> contraceptive supply <strong>and</strong> dem<strong>and</strong>; (b)governance <strong>and</strong> policy models for contraceptive securitywill vary country to country where no one programmemodel will fit every situation; <strong>and</strong> (c) factors <strong>in</strong>fluenc<strong>in</strong>g<strong>in</strong>dividual contraceptive dem<strong>and</strong> will be wide rang<strong>in</strong>g,not just across but also with<strong>in</strong> countries. Social normswill play a role <strong>in</strong> ideational change around sexual activity,gender responsibility for <strong>and</strong> roles <strong>in</strong> plann<strong>in</strong>g pregnancy<strong>and</strong> <strong>the</strong> preference for contraceptive method. Trends <strong>in</strong>gender equity <strong>in</strong> access to educational, employment <strong>and</strong>economic opportunities will raise contraceptive dem<strong>and</strong><strong>and</strong> <strong>in</strong>teract with social environmental changes <strong>and</strong> stageof <strong>the</strong> reproductive lifespan. For example, a rise <strong>in</strong> condomuse among urban couples <strong>in</strong> nor<strong>the</strong>rn India has beenobserved, although at <strong>the</strong> completion of childbear<strong>in</strong>g <strong>the</strong>ireventual method of choice may be female sterilization, anevent that is occurr<strong>in</strong>g at <strong>in</strong>creas<strong>in</strong>gly younger ages ( Ja<strong>in</strong>et al., 2010). Social market<strong>in</strong>g of <strong>and</strong> improved access tocondoms <strong>in</strong> urban areas may be enabl<strong>in</strong>g couples to practisebirth spac<strong>in</strong>g, as well as satisfy <strong>the</strong>ir preferences for thismethod. Condom use is much higher <strong>in</strong> urban than ruralareas of India, <strong>and</strong> <strong>in</strong> <strong>the</strong> nor<strong>the</strong>rn than sou<strong>the</strong>rn statesof that country. Such <strong>in</strong>ternal variation at early stages offamily formation is likely to be replicated <strong>in</strong> o<strong>the</strong>r sett<strong>in</strong>gsas sophistication with <strong>the</strong> practice of fertility-regulat<strong>in</strong>gmethods exp<strong>and</strong>s.Unsatisfied contraceptive dem<strong>and</strong>, i.e., unmet need, varieswidely as well, as <strong>in</strong>dicated <strong>in</strong> countries where data areavailable. Laos, Maldives <strong>and</strong> Pakistan register some of<strong>the</strong> highest levels of unmet need (40%, 37% <strong>and</strong> 33%respectively) <strong>in</strong> <strong>the</strong> region. Unmet need is substantial forCambodia (25%), Nepal (24%), Myanmar (20%), <strong>the</strong>Philipp<strong>in</strong>es (17%), <strong>the</strong> Democratic People’s Republic ofKorea (16%) <strong>and</strong> Mongolia (14%). These levels occuramong married couples where <strong>the</strong> wife is not practis<strong>in</strong>gcontraception but desires to space or limit future births;<strong>the</strong>se levels imply cont<strong>in</strong>ued vulnerability to <strong>the</strong> risk ofan unplanned pregnancy until <strong>the</strong> need is met. Globallythis figure is estimated to be 215 million women, with apredom<strong>in</strong>ant share be<strong>in</strong>g <strong>in</strong> <strong>the</strong> <strong>Asia</strong>n region, <strong>and</strong> <strong>the</strong><strong>in</strong>cidence of un<strong>in</strong>tended pregnancies is estimated at 75million annually (S<strong>in</strong>gh et al., 2009).At <strong>the</strong> same time, it is evident that reduc<strong>in</strong>g unmet needto zero or negligible levels is possible <strong>and</strong> nearly assuredwhere contraceptive prevalence is high, e.g., <strong>in</strong> Viet Namwith 5 per cent unmet need <strong>and</strong> Indonesia with 9 per cent.This <strong>in</strong>dicator is one through which progress towardsachiev<strong>in</strong>g MDG 5b is be<strong>in</strong>g monitored, <strong>and</strong> zero tolerancefor unmet contraceptive need merits consideration foradoption by all countries fully committed to improv<strong>in</strong>g <strong>the</strong>human condition. The cost-effectiveness of contraceptionre<strong>in</strong>forces <strong>the</strong> social <strong>and</strong> health value of its universal access.In terms of cost per disability-adjusted life year (DALY),modern contraceptive methods cost $62 (<strong>in</strong> 2008 UnitedStates dollars), compared with <strong>the</strong> cost for anti-retroviral<strong>the</strong>rapy ($150 <strong>in</strong> India or $252-$547 <strong>in</strong> sub-SaharanAfrica) or <strong>the</strong> cost for oral rehydration <strong>the</strong>rapy ($1,268)(S<strong>in</strong>gh et al., 2009).Recent calculations from <strong>the</strong> Health Policy Initiativeproject of <strong>the</strong> Futures Group show that contributionsfrom meet<strong>in</strong>g unmet need for family plann<strong>in</strong>g can reduce55